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Oderda M, Marquis A, Sasia A, Calleris G, Dematteis A, D'Agate D, Falcone M, Lavagno F, Marra G, Montefusco G, Gontero P. Lateral versus anterior approach for bladder neck dissection during robot-assisted radical prostatectomy: a pair-matched analysis to evaluate urinary continence and surgical margins. MINIM INVASIV THER 2024:1-7. [PMID: 38915259 DOI: 10.1080/13645706.2024.2369096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION The preservation of the bladder neck during robot-assisted radical prostatectomy (RARP) could improve urinary continence recovery and limit the risk of positive surgical margins (PSMs). We refined our lateral approach to the bladder neck technique and compared its outcomes with those of the standard anterior approach. MATERIAL AND METHODS From a retrospective analysis of 599 consecutive RARPs, 171 patients treated with the lateral and 171 patients treated with the anterior approach were pair-matched 1:1 on the basis of age, grade, and pathological stage. We described our surgical technique and compared the two approaches in terms of basal PSMs, recovery of urinary continence, and complications. RESULTS As compared to the anterior approach, the lateral approach had shorter operative times and comparable rates of basal PSMs and postoperative complications. The rates of urinary continence after one, three, and 12 months were comparable between the two groups and were generally higher in localized disease. At regression analysis, predictors of urinary incontinence were only age, pathological stage T3b, ISUP grade 5 and nerve-sparing surgery. CONCLUSIONS The lateral approach leads to an anatomical dissection of the bladder neck without increasing the risk of PSMs. However, no significant benefits in terms of continence recovery were demonstrated over the standard anterior approach.
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Affiliation(s)
- Marco Oderda
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Alessandro Marquis
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Alberto Sasia
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Giorgio Calleris
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Alessandro Dematteis
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Daniele D'Agate
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Falcone
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Federico Lavagno
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | | | - Gabriele Montefusco
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
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Xiangyun L, Zhen L, Mengyao H, Lin Z, Xiaonan S, Jingxiong W, Chunhui L, Wenwen C, Weigang Y, Yancai L. Curative effect of pelvic floor muscle exercise on urinary incontinence after radical prostatectomy—Comparisons of different approaches at different time point. Andrologia 2022; 54:e14373. [PMID: 35279870 DOI: 10.1111/and.14373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/01/2022] [Accepted: 01/04/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lu Xiangyun
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Liang Zhen
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Hu Mengyao
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Zhou Lin
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Sun Xiaonan
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Wu Jingxiong
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Liu Chunhui
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Chen Wenwen
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Yan Weigang
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
| | - Liang Yancai
- Department of Urology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Dongcheng District, Beijing China
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Vis AN, van der Poel HG, Ruiter AE, Hu JC, Tewari AK, Rocco B, Patel VR, Razdan S, Nieuwenhuijzen JA. Posterior, Anterior, and Periurethral Surgical Reconstruction of Urinary Continence Mechanisms in Robot-assisted Radical Prostatectomy: A Description and Video Compilation of Commonly Performed Surgical Techniques. Eur Urol 2019; 76:814-822. [DOI: 10.1016/j.eururo.2018.11.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/15/2018] [Indexed: 11/25/2022]
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Checcucci E, Veccia A, Fiori C, Amparore D, Manfredi M, Di Dio M, Morra I, Galfano A, Autorino R, Bocciardi AM, Dasgupta P, Porpiglia F. Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes. BJU Int 2019; 125:8-16. [PMID: 31373142 DOI: 10.1111/bju.14887] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP). MATERIALS AND METHODS After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed. RESULTS A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004). CONCLUSION Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.
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Affiliation(s)
- Enrico Checcucci
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Alessandro Veccia
- Urology Unit, ASST Spedali Civili Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Science, and Public Health, University of Brescia, Brescia, Italy.,Division of Urology, VCU Health, Richmond, VA, USA
| | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Daniele Amparore
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Matteo Manfredi
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Michele Di Dio
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Ivano Morra
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | | | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
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Abstract
Objective: The optimal management strategy for prostate cancer (PCa) remains controversial. We performed a systemic review of current progress and controversies regarding the diagnosis and treatment of PCa. Data Sources: We searched PubMed for recently published articles up to July 2017 using the following key words: “prostate cancer,” “progress,” “controversy,” “immunotherapy,” and “prevention.” Study Selection: Articles were obtained and reviewed to provide a systematic review of the current progress and controversies regarding PCa management. Results: The value of serum prostate-specific antigen (PSA) screening remains controversial, but PSA screening is recommended to facilitate the early diagnosis of PCa in high-risk groups. Prostate biopsy via the transrectal or perineal approach has both advantages and disadvantages. There was a significant correlation between testosterone levels and PCa prognosis. The current research is focused on the mechanisms responsible for PCa. Active surveillance has been proposed as a management strategy for low-risk, localized PCa, but there is an urgent need for further clinical studies to establish the criteria for recommending this approach. The main complications of radical resection for PCa are urinary incontinence and erectile dysfunction, though three-dimensional laparoscopic and robot-assisted laparoscopic techniques have obvious advantages over radical surgery. Radiotherapy is also a therapeutic option for PCa, while immunotherapies may alter the prostate tumor microenvironment. Ongoing studies aim to provide guidance on effective sequential and combination strategies. Prevention remains an important strategy for reducing PCa morbidity and mortality. Conclusions: The diagnosis, treatment, and prevention of PCa are complex issues, worthy of intensive study. Further studies are needed to improve the management of PCa.
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Affiliation(s)
- De-Xin Dong
- Department of Urology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, China
| | - Zhi-Gang Ji
- Department of Urology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, China
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Bartoletti R, Mogorovich A, Francesca F, Pomara G, Selli C. Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery. BMC Urol 2017; 17:119. [PMID: 29246146 PMCID: PMC5732441 DOI: 10.1186/s12894-017-0308-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/28/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To evaluate the effects of combined bladder neck preservation and posterior reconstruction techniques on early and long term urinary continence in patients treated by robotic assisted radical prostatectomy (RARP). METHODS Two-hundred ninety-two patients who previously underwent radical prostatectomy were retrospectively selected for a case-control study, excluding those with anastomotic strictures and significant perioperative complications and re-called for a medical follow-up visit after their consent to participate the study. They were divided in 3 different groups according to the surgical technique previously received: radical retropubic prostatectomy (RRP) combined with bladder neck preservation (BNP), RARP with bladder neck resection, and RARP combined with BNP and posterior musculofascial reconstruction (PRec). Functional and oncologic outcomes evaluation were integrated by a questionnaire on urinary continence status, abdominal ultrasound scan, uroflowmetry and post-void urine volume measurement. Urinary continence definition included the terms "no pad" or "safety pad". RESULTS Two hundred thirty-two patients responded to the phone call interview and were enrolled in the study. They presented comparable age, prostate volume and BMI. Differences in comorbidities, ASA score and medications, did not influence the postoperative functional results, focused on continence outcome. Early urinary continence was achieved in 49.38% and 24.73% of patients who previously underwent RARP + BNP + PRec and simple RARP respectively (p = 0.000)as well as late 12-months urinary continence was obtained in 92.59% and 79.56% of patients.(p = 0.01). Late urinary continence in the RRP + BNP group was comparable to the result obtained in the simple RARP group. The potential effects of nerve sparing technique on urinary continence have not been evaluated. CONCLUSIONS The combined technique of RARP + BNP + PRec seems to be effective to determine early and long term significant effects on urinary continence of patients with comparable body mass index, age and prostate volume. No statistically significant differences were found between the simple RARP and the RRP + BNP groups.
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Affiliation(s)
- Riccardo Bartoletti
- Urology Unit University of Pisa, Pisa, Italy
- Urology University Unit, Cisanello Hospital, Via Paradisa 2, 56124 Pisa, Italy
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Hashimoto T, Yoshioka K, Gondo T, Hasama K, Hirasawa Y, Nakashima J, Tachibana M, Ohno Y. The Impact of Lateral Bladder Neck Preservation on Urinary Continence Recovery After Robot-Assisted Radical Prostatectomy. J Endourol 2017; 32:40-45. [PMID: 28978229 DOI: 10.1089/end.2017.0459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Urinary incontinence is one of the most bothersome adversities after robot-assisted radical prostatectomy (RARP). The aim of this study was to investigate the urinary continence recovery and the effect of various surgical techniques. MATERIALS AND METHODS We previously reported that posterior rhabdosphincter reconstruction and nerve-sparing were independent predictors of urinary continence recovery 1 month after catheter removal in 199 patients who underwent RARP. Retrospectively, we further reviewed those 199 patients for urinary continence recovery at 3 months or later after RARP. The relationships of urinary continence with perioperative findings, including surgical procedures, were evaluated at 3 to 12 months after RARP. The Fisher exact test and Mann-Whitney rank sum test were used for evaluating variables between the groups. Multivariate logistic regression analysis was performed to investigate the association between urinary continence and perioperative factors. RESULTS On univariate analyses, surgeon experience, lateral bladder neck preservation (BNP), anterior reconstruction, and posterior reconstruction were significantly associated with urinary continence recovery 3 months after RARP, but only lateral BNP was independently associated with urinary continence recovery in a multivariate analysis. Similarly, on univariate analyses, surgeon experience, lateral BNP, and posterior reconstruction were significantly associated with continence recovery at 6 months or later after surgery. However, multivariate analyses showed that only lateral BNP was significantly associated with urinary continence recovery 6 months or later after surgery. CONCLUSION Although the lateral BNP technique did not affect immediate urinary continence recovery, this procedure was significantly associated with continence recovery 3 months or later after RARP.
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Affiliation(s)
| | - Kunihiko Yoshioka
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan .,2 Institute for Urology , Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Tatsuo Gondo
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan
| | - Kazuki Hasama
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan
| | - Yosuke Hirasawa
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan
| | - Jun Nakashima
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan .,3 Department of Urology, Sanno Hospital , Tokyo, Japan .,4 Clinical Medicine Research Center, International University of Health and Welfare , Tokyo, Japan
| | | | - Yoshio Ohno
- 1 Department of Urology, Tokyo Medical University , Tokyo, Japan
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Tsikis ST, Nottingham CU, Faris SF. The Relationship Between Incontinence and Erectile Dysfunction After Robotic Prostatectomy: Are They Mutually Exclusive? J Sex Med 2017; 14:1241-1247. [DOI: 10.1016/j.jsxm.2017.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 07/19/2017] [Accepted: 08/01/2017] [Indexed: 12/01/2022]
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Yamada Y, Fujimura T, Fukuhara H, Sugihara T, Nakagawa T, Kume H, Igawa Y, Homma Y. Predictors of Early Continence after Robot-assisted Radical Prostatectomy. Low Urin Tract Symptoms 2017; 10:287-291. [PMID: 28699263 DOI: 10.1111/luts.12181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/03/2017] [Accepted: 03/27/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Our objective was to investigate predictors of early continence outcome after robot-assisted radical prostatectomy (RARP). METHODS Clinical records were prospectively collected in 272 patients who underwent RARP. Clinical parameters, continence rates, and time to achieve continence were investigated and analyzed. Recovery of continence was defined as achieving complete continence (pad-free). RESULTS In the univariate analysis, young age (≤67 years) and low pT stage (≤pT2) were significantly associated with continence achieved within 2 weeks after RARP (P = 0.0343 and P = 0.0406, respectively). Low prostate weight was the only factor associated with recovery of continence within 1 month (P = 0.0461). Multivariate analysis revealed that young age (≤67 years) and low pT stage (≤pT2) were statistically significant predictors of continence within 2 weeks after RARP (P = 0.040 and P = 0.015, respectively). CONCLUSION Young age and low pT stage were independent predictors of early continence.
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Affiliation(s)
- Yuta Yamada
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Fujimura
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Sugihara
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tohru Nakagawa
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhiko Igawa
- Department of Continence Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukio Homma
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Tyson MD, Ark J, Gregg JR, Johnsen NV, Kappa SF, Lee DJ, Smith JA. The Null Effect of Bladder Neck Size on Incontinence Outcomes after Radical Prostatectomy. J Urol 2017; 198:1404-1408. [PMID: 28655528 DOI: 10.1016/j.juro.2017.06.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size. RESULTS A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th percentile for bladder neck size (18 mm) with the 10th percentile (7 mm) revealed no significant difference in adjusted EPIC scores for incontinence at 6 weeks (β coefficient 0.88, 95% CI -10.92-12.68, p = 0.88) or at 12 weeks (β coefficient 5.80, 95% CI -7.36-18.97, p = 0.39). CONCLUSIONS These findings question the merit of creating an extremely small bladder neck during robot-assisted laparoscopic radical prostatectomy. We contend that doing so increases the risk of positive margins at the bladder neck without facilitating early recovery of continence.
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Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona.
| | - Jacob Ark
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Justin R Gregg
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Niels V Johnsen
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Stephen F Kappa
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Daniel J Lee
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Joseph A Smith
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
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